#251 What the USPSTF?

January 18, 2021 | By Paul Williams

Preventive Medicine Updates with Dr. Amber-Nicole Bird

What the USPSTF?! It’s time for some preventive medicine updates on: screening for unhealthy drug use, cervical cancer, hepatitis C and draft recs for colorectal cancer; plus how to interpret USPSTF screening recs. Dr. Amber-Nicole Bird @ABirdMD (Penn Medicine) refreshes our love for preventive medicine, with updates on the newest recommendations. She reviews how to appropriately interpret and adopt guidelines for our patients, being cognizant of the source. We shine light on the mechanism of USPSTF, including how their guidelines differ from others, so we can understand the value and context when utilizing the guidance in the clinic.

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Credits

• Produced and Written by: David Madick MD; Peter Wikoff MD; Paul Williams MD, FACP
• Infographic: Beth Garbitelli
• Cover Art: Chris Chiu MD
• Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Editor: Emi Okamoto, MD (Show notes); Clair Morgan of nodderly.com
• Guest: Amber-Nicole Bird, MD 

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Time Stamps*

*Note: Time Stamps refer to ad free version. 

• 00:00 Intro, disclaimer, guest bio
• 02:40 Guest one-liner, Book recommendation, Favorite failure
• 07:35 USPSTF background
• 11:22 Level of certainty and grade
• 16:32 Screening for unhealthy drug use
• 26:32 Screening for hepatitis C
• 31:45 Cervical cancer screening
• 43:30 Choosing which guidelines to follow
• 49:06 Colorectal cancer screening draft
• 58:00 Non-evidence based screening
• 62:00 Take home points and Outro

Preventive Medicine Updates Pearls

1. Preventive medicine is complex and a powerful tool! Consider who generates the guidelines and the benefit:risk for your population
2. The USPSTF is a volunteer task force made up of experts in preventive medicine
3. Recommendations are for asymptomatic individuals and based on balancing harms and benefits; cost is not a consideration
4. The USPSTF recommendation for screening for unhealthy drug use has been updated.  Verbally screen all adults for unhealthy drug use (not laboratory-based) if you can do something about a positive screen
5. The NIDA tool is a quick and effective tool for screening for unhealthy substance use
6. The USPSTF has updated their hepatitis C screening to include all adults ages 18-79 years; use a hepatitis C antibody test with reflex to RNA
7. The American Cancer Society has updated its guidelines for cervical cancer screening: (a) start screening at age 25 (b) primary HPV testing is the preferred test done every 5 years (c) stop screening after age 65 years (if prior 10 years normal screening or no CIN2 or higher  in last 25 years) 
8. At the time of these notes, there is a USPSTF draft recommendation for colorectal cancer screening that recommends lowering the age to start screening to 45 years

Preventive Screening Updates Notes

United States Preventive Services Task Force Background

• Independent, volunteer task force made up of experts in preventive medicine
• Volunteers from all areas of preventive medicine, including behavioral health, nursing, and gynecology
• Tasked with studying prevention in a clinical context
• Synthesize guidelines from existing research
• Key points: Looking at asymptomatic individuals and looking at harms versus benefits
• Cost is NOT a consideration when making recommendations
• USPSTF will consider any public request for an update

Grades and Levels of Certainty

• USPSTF has 3 levels of certainty: Low, moderate, and high
  • Based on the quality of existing data
  • High certainty: Consistent results from well-designed studies in a representative primary care population
  • Moderate certainty: Can determine an impact, and can assess recommended service, but imperfect data
  • Low certainty: Flawed data, and cannot assess impact of service on overall outcomes
• USPSTF grades
  • Like you’d think, A and B are services that have more benefit than harm – do these!
  • Grade C services need to be individualized to specific populations
  • Grade D items are discouraged – harm greater than benefit
  • Grade I (“I don’t know”) – cannot fully assess evidence of benefit versus harm

Screening for Unhealthy Drug Use

• USPSTF recommends screening for unhealthy drug use in adults age 18 years or older (Grade B, moderate certainty)
• Different from screening for tobacco and alcohol use, which are addressed in different guidelines
• Per USPSTF, data show net benefit to screening for unhealthy drug use, IF you can effectively offer treatment directly or via referral
  • Driven in part by data for medications for opioid use disorder, as well as some behavioral health interventions
• Guideline is specifically for VERBAL screening
  • No indication for laboratory-based screening
• Dr. Bird favors the NIDA screening tool for unhealthy drug use
  • Includes screening for alcohol and tobacco use as well
  • Links to the ASSIST tool, which can provide recommendations for management

Screening for Hepatitis C

• USPSTF recommends screening everybody aged 18-79 years at least once for hepatitis C infection
  • Upper age limit based on existing safety data of treatment
• Grade B recommendation, with moderate certainty of substantial net benefit
• Based on availability of effective, low harm treatments and increased prevalence of hepatitis C infection in adults
• Screen with antibody testing as initial test, with reflex to RNA testing

Cervical Cancer Screening

• As with much in preventive care, there are multiple screening guidelines from different societies and organizations
• USPSTF guidelines, updated in 2018 (Grade A, high certainty)
  • Added on the option of primary high risk HPV testing every 5 years in ages 30-65 (alone or co-testing with cytology). 
  • Cytology alone every 3 years is still an option in age 30-65, and the recommended method for age 21-29.
• American Cancer Society updated their guidelines in 2020
  • Increased age to initiate screening to 25 years
    • Incidence of cervical cancer in women ages 21-24 is low
      • Accounts for less than one percent of patients with cervical cancer
  • Primary HPV testing every 5 years until the age of 65 years is preferred testing for all women undergoing cervical cancer screening
    • If not available, co-testing every 5 years or cytology only every 3 years (this is a transitional recommendation; will be removed from future guidelines)
  • Provides clear recommendations to stop screening after the age of 65 years
    • Requires adequate and normal screening for the 10 years prior
    • No CIN 2 or higher in past 25 years
• Recommendation to phase out cytology probably based in part on impact of HPV vaccination
• Incidence of cervical cancer is declining following routine HPV vaccination
• Cytology less efficient in vaccinated populations
  • Disproportionately detects minor abnormalities associated with HPV types that are at lower risk of causing cancer

Colorectal Cancer Screening

• USPSTF released draft recommendation for colorectal cancer screening in October of 2020
  • Part of a process to put up recommendations for public comments
  • Insurance may not cover screening recommendation changes until they are finalized
• Draft recommendation recommends screening for colorectal cancer in adults aged 45 to 79 years (Grade B, moderate certainty) and adults aged 50 to 75 years (Grade A, high certainty)
  • Screening modalities can be stool-based (high-sensitivity guaiac-based FOBT, fecal immunochemical test, and stool DNA test) or direct visualization (colonoscopy, CT colonography, and flexible sigmoidoscopy).
• USPSTF also recommends selectively offering colorectal cancer screening in adults aged 76 to 85 years (Grade C, moderate certainty)

Links*

1. Evicted: Poverty and Profit in the American City by Matthew Desmond
2. Cyberpunk 2077 (cut from final audio)
3. USB Rechargeable headlamp (cut from final audio)
4. Sign up for USPSTF updates
5. ASCCP app or web application  – American Society for Colposcopy and Cervical Pathology
6. Fightcolorectalcancer.org

Goal

Listeners will understand recent updates to preventive medicine guidelines and the rationale.

Learning objectives

After listening to this episode listeners will…  

1. Understand the structure and role of the United States Preventive Service Task Force
2. Discuss the relevance and process of draft USPSTF recommendations
3. Screen for unhealthy drug use in a primary care population
4. Apply hepatitis C screening to adult patients
5. Compare and contrast the USPSTF and ACS screening guidelines for cervical cancer
6. Explain the changes to the new draft USPSTF recommendation for colorectal cancer screening

Disclosures

Dr. Bird reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Madnick D*, Wikoff P*, Bird A, Williams PN, Brigham SK, Watto MF. “#251 What the USPSTF? Preventive Medicine Updates with Dr Amber Nicole Bird”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date January 18, 2021.